In recent years, much attention has been brought to the standard of care Veterans are receiving at VA facilities. While private facilities have also been scrutinized and feeling pressure to improve standards, the VA appears to be doing less to improve the conditions. According to a report released by the Government Accountability Office, investigations called root cause analyses (RCA) have gone down, but the number of adverse events have gone up over 7 percent. Adverse Events are defined “as incidences that pose a risk to a patient as the result of a medical intervention or the lack of an appropriate intervention.”
It is unclear as to why the RCA have gone down, but perhaps the reporting of negligent events are left to the discretion of the employee. It should also be noted that a minimum of eight RCA’s are to be investigated per year. This being said, in an environment where employees are paranoid about making mistakes, losing their jobs, or losing bonus based on performance or their lack of, is it prudent to believe that they would be reporting and investigating these mistakes earnestly?
The Department of Veterans Affairs runs a health care system that provides medical care to almost 6 million Veterans as of last year, and that number will only continue to increase. What is most disturbing about these new statistics, is that it has not raised red flags of concern. When questioned about the drop in investigations, the VA did not have a reason why the change occurred even though negligence was on the rise, nor did they seem interested in finding the root cause. With a growing number of Veterans who will be seeking care, it is in everyone’s best interest that these problems be addressed. The National Center for Patient safety is quoted as saying,” has limited awareness as to what hospitals are doing to address the root causes of adverse events.”
The report revealed that a new “safety culture” has evolved within many of the VA facilities, which does not appear to be making the hospitals safer, in fact according to the report mentioned in the Washington Post, has created a potentially more dangerous environment. There is no excuse for any “adverse event” to go unreported, and if the Veterans Affairs employees continue to cover up mistakes, no matter how benign or not, the opportunity to have an honest attempt at finding solutions is lost. Rather than having the mentality of blame or fear in the work place, which may be creating this new “safety culture”, which is anything but, the VA should focus more on solving these problems. Our Veterans are deserving of a much higher standard.